How to manage: acute severe colitis

Abstract

Acute severe ulcerative colitis (ASUC) is a medical emergency which is associated with significant morbidity and a mortality rate of 1%. ASUC requires prompt recognition and treatment. Optimal management includes admission to a specialist gastrointestinal unit and joint management with colorectal surgeons. Patients need to be screened for concomitant infections and thromboprophylaxis should be administered to mitigate against the elevated risk of thromboembolism. Corticosteroids are still the preferred initial medical therapy but approximately 30%–40% of patients fail steroid therapy and require rescue medical therapy with either infliximab or cyclosporine. Emergency colectomy is required in a timely manner for patients who fail rescue medical therapy to minimise the risk of adverse post-operative outcomes. We discuss current and emerging evidence in the management of ASUC and outline management approaches for clinicians involved in managing ASUC.

Identification and surgical management of acute severe ulcerative colitis: A guide for general practitioners

“…As shown in Figure 1, the clinician might assess for ova, cysts and parasites (OCP), viral, and bacterial infections, including Clostridium difficile toxin, with a stool microscopy, culture and sensitivity study. 3,5,11 Additionally, a faecal calprotectin assay can assess disease severity; a calprotectin level >50 mcg/g might represent active inflammation. 12 Diagnostic imaging, including abdominal radiography, is used to identify toxic megacolon.…”

“…13 It also facilitates prompt histological biopsies (eg for cytomegalovirus). 11 It should be performed at the earliest opportunity, with various studies demonstrating improved outcomes in ASUC patients undertaking endoscopy within 72 hours of hospitalisation. 13…”

“…Initial medical management includes intravenous glucocorticoids with potential escalation to a biologic agent (usually infliximab) 3,11,15,16 and aims to reduce colectomy rates by up to 80%. [17][18][19][20] Medications that harbour a potential risk of inducing colonic dilatation should be used cautiously (eg anticholinergics, antidiarrheals and opiates).…”

Management of refractory inflammatory bowel disease

“…Steroid nonresponse at 72 h carries a high-risk of colectomy, and rescue therapy, traditionally with IFX or cyclosporine (CYS), is warranted at this point. Daily assessment of stool frequency, haematochezia, abdominal pain, C-reactive protein, albumin and haemoglobin should be performed to monitor overall improvement [50].…”

“…Acute severe ulcerative colitis ASUC, as defined by the criteria by Truelove and Witts, is a potentially life-threatening condition, which affects 25% of ulcerative colitis patients in their lifetime and should be addressed in a coordinated multidisciplinary approach between hospitalists, gastroenterologists, colorectal surgeons and nutritionists [49]. An early unprepped sigmoidoscopy should be performed to evaluate disease severity and to obtain biopsies for CMV [50]. It is important to assess for infectious causes, such as C. difficile and CMV, although it may be difficult at times to distinguish whether these organisms truly drive a flare or are simply bystanders.…”